Surgical technique: does mini-invasive medial collateral ligament and posterior oblique ligament repair restore knee stability in combined chronic medial and ACL injuries?

Abstract

Background: Residual laxity remains after ACL reconstruction in patients with combined chronic ACL and medial instability. The question arises whether to correct medial capsular and ligament injuries when Grade II and III medial laxity is present.

Description of technique: We developed a mini-invasive medial ligament plasty to repair the medial collateral ligament to correct residual medial valgus and rotatory laxity after ACL reconstruction.

Patients and methods: We prospectively followed 36 patients with an ACL deficiency combined with chronic Grade II or III valgus and rotatory medial instability. The mean age was 37 years (range, 15-70 years). For all patients, we obtained preoperative and postoperative Knee Injury and Osteoarthritis Outcome, International Knee Documentation Committee, Lysholm, and Tegner Activity Level Scores. The minimum followup was 2 years (median, 3 years; range, 2-7 years).

Results: The mean subjective International Knee Documentation Committee score improved from 36 preoperatively to 94 at the last followup. While all patients had an International Knee Documentation Committee score of Grade C or D preoperatively, no patient did postoperatively. The mean Knee Injury and Osteoarthritis Outcome Score improved from 45 preoperatively to 93 postoperatively. Valgus and external rotatory tests were negative in all patients. The mean Tegner activity level decreased from 7 preinjury to 6 postoperatively, and the mean Lysholm score improved from 40 preoperatively to 93 at last followup.

Conclusions: This simple technique restored medial stability and knee function to normal or nearly normal in all patients.

Level of evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

A photograph shows how the medial compartment is still open after ACL fixation. The probe is positioned at the inner border of the middle horn of the medial meniscus.

Fig. 2

A photograph shows the small incision over the medial epicondyle.

Fig. 3

A photograph shows the laxity of the medial compartment.

Fig. 4

The photograph shows the lax medial tissue tightened up to the epicondyle; note the sutures of the POL.

Fig. 5

The photograph shows the nonabsorbable sutures of the MCL.

Fig. 6

The photograph shows sutures at the end of the procedure: the MCL and POL have been advanced proximally to the medial epicondyle.

Fig. 7

The photograph shows the sutures of the retinaculum.

Fig. 8

The photograph shows the physiologic gap of the medial compartment at the end of the procedure.